Risk and Mental Health Practice
Risk and Mental Health Practice
Issue 46 – December 2015Author: Anne Felton (Anne.Felton@nottingham.ac.uk)
- Risk management dominates mental health practice.
- Current approaches to risk assessment limit a full understanding of threats to a person’s safety as well as inhibit recovery.
Implications for practice
- The risks services pose to people needs to be recognised
- Closer connections with people’s individual narratives can inform a relational approach to risk assessment.
Risk and mental health practice.The assessment and management of risk is increasingly central to mental health practice 1. Risk has become a key factor in decision-making within service users’ care and containing risk is recognised as a vital skill for mental health professionals2. Supporting recovery within this context is challenging, and in order to move beyond the tensions between risk and recovery, it is important to question the role risk occupies in mental health practice. As mental health services moved from institutional to community based models of care in the late twentieth century, the way in which we understand risk has shifted. Instead of the potential for harm being recognised on an individual basis, mental health professionals are now required to identify and measure a series of risk factors that became associated with all people who use mental health services. Such a shift is problematic for a number of reasons. Firstly the association of these risk factors with all those who use services perpetuates a view that people with mental health problems cause harm. In addition, an increasingly technical process is created as the focus is removed from the person themselves onto paper based tools1, which act to exclude service users from decisions about risk3. Finally, the emphasis on completion of risk assessment tools also acts to narrow conceptualisations of potential harms. Within such tools risks are defined as those perpetrated by service users, either to themselves or others, rather than the harms that they experience, through for example the side effects of psychiatric medication, loss of civil liberties, status, physical health and environmental safety. A focus on the assessment of risk in this way presents risk as a knowable quantifiable concept. This has benefits in seeming to make the future predictable, reflecting a modern system of beliefs which speaks to our desires to feel like we have control over uncertainty and danger2. However, the evidence for the predictive ability of risk assessment tools is poor4 5 , in part because of the rareness of the events that we are attempting to predict6. Unfortunately these approaches to risk assessment can expose people to unnecessary restrictions and inhibit the opportunities available to service users to work towards recovery.
Organisational contextPatient safety has a greater focus than ever before in health services particularly in light of high profile incidents such as Mid-Staffordshire, which can present further opportunities to think differently about risk and safety. For example, a recent briefing from ‘Implementing Recovery through Organisational Change’ (ImRoc) highlights how “implementing a recovery orientated approach to risk and safety would simultaneously fulfil many of the ambitions for improved practice and patient safety described in the Francis report”8. Consistent with this approach, clinical judgements which go beyond narrow risk assessment tools can help facilitate positive risk taking. Indeed professional guidelines and policy consistently outline a need to balance safety with the promotion of autonomy7. However, organisational cultures can constrain a broader focus on risk and contribute to a fear for mental health professionals of being blamed if anyone should come to harm. This influences a skewing in the balance, towards increased containment and control.
A relational approach to risk and safety.The prominence of risk in mental health practice, contributes to a situation in which it can dominate professionals’ perceptions of service users9. Focusing on a series of risk factors not only restricts our understanding of what these harms are, but also can distance us from the trauma and emotional distress that people may be experiencing. Re-engaging with the person’s own narrative situates an understanding of risk within the context of a relationship. This provides a space for exploring threats to the person’s own safety, such as victimisation, stigma or the physical effects of psychiatric medication as well as the everyday risks we are all involved in taking by exposing ourselves to new experiences 10 11. This presents an opportunity to move away from service users as the source of risk alongside recognition of the potential gains that may be achieved through the person taking more control. Co-produced safety plans, open and honest discussions about the risk assessment process and the outcomes of that process are being called for as ways to challenge the current conceptualisation of risk. I would also argue that it’s vital to ensure that there is a greater connection with service users in the decision making process, as only then will we be able to develop approaches that enable us to hold uncertainty, promote safety and facilitate recovery.
- Godin, P. (2004) ‘You don’t tick boxes on a form’: a study of how community mental health nurses assess and manage risk. Health, Risk and Society, 6(4), 347-360
- Szmukler, G. & Rose, N. (2013). Risk assessment in mental health care: Values and costs. Behavioral sciences & the law, 31(1), 125-140.
- Langan, J. & Lindow, V. (2004). Living with Risk Mental Health service user involvement in risk assessment and management .Bristol: Joseph Rowntree Foundation, Policy Press
- Fazel, S., Singh, J., Doll, H. & Grann, M. (2002). ’Use of risk assessment instruments to predict violence and antisocial behaviour in 72 samples involving 24,827 people: a systematic review and meta-analysis British Medical Journal, 345, 1-12
- Wand, T. (2011). Investigating the evidence for the effectiveness of risk assessment in mental health care. Issues in mental health nursing 33(1), 2-7.
- Goldacre, B. (2006). It’s not easy to predict murder – do the maths. The Guardian Available at http://www.theguardian.com/science/2006/dec/09/badscience.uknews [Accessed 25/6/2013]
- Department of Health (2007) Best practice in Managing Risk: Principles and evidence for best practice in the assessment and management of risk to self and others in mental health services. London. TSO.
- 8 Boardman, G.& Roberts, G. (2014). Risk, Safety and Recovery: a briefing (ImRoc). London: Centre for Mental Health / NHS confederation.
- Felton, A. (2015). Psychiatry is a risk business’ the construction of mental health service users as risk objects; a multiple case study inquiry. Unpublished PhD Thesis.10.Muir-Cochrane, E. (2006). Medical co-morbidity risk factors and barriers to care for people with schizophrenia. Journal of psychiatric and mental health nursing, 13(4), 447-452.
- Langan, J. (2008) Involving mental health service users considered to pose a risk to other people in risk assessment. Journal of Mental Health 17(5), 471-481
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